Dialogue is a prerequisite for the nurse–patient relationship in nutritional care: A secondary analysis using the fundamentals of care framework

Abstract Background Providing good nutritional care is complex as it goes beyond assessing and ensuring the patients' dietary needs. So far, nutritional research has mainly focused on establishing evidence for the nutritional treatment, while less attention has been on the complexity of providing nutritional care. The Fundamentals of Care (FoC) describes five elements (focus, knowledge, anticipate, evaluate and trust) essential for establishing a nurse–patient relationship as a foundation for quality care. By studying how these elements shape nutritional care and dialogue, we can explore and describe the complexity of nutritional care. Aim By using the FoC framework as an analytic framework, this study explores how the nurse–patient relationship shapes the nutritional care of orthopaedic patients. Method This study is a secondary analysis using deductive content analysis of interviews with patients undergoing major orthopaedic surgery, nursing staff and observations of interactions between nursing staff and patients. The core dimension of the FoC framework, ‘Establishment of relationship,’ was used as an analytic framework. Result The nurses perceived serving meals and providing nutritional supplements as an essential part of the nutritional care. Still, the nutritional care was organised as a routine task to be less time‐consuming. Appropriate care was initiated when the nursing staff explored patients´ food preferences. When the nursing staff failed to familiarise themselves with the patient's preferences, the patients interpreted nutritional care as unrelated to their needs, resulting in a lack of trust. Conclusion The need for efficiency within nutritional care must not compromise the patients' need for dialogue with the nurse. Establishing a trusting relationship between nurses and patients prevents nutritional care from becoming a routine task unrelated to the patients' needs.


INTRODUCTION
Caring for malnourished patients can be challenging [1] as nutritional problems are often complex and go beyond dietary intake [2]. The prevalence of malnutrition is between 20% and 50% amongst hospitalised patients +65 years of age [3][4][5]. These numbers also apply to older orthopaedic patients [6,7]. Malnutrition increases the risk of muscle loss and loss of motor independence in older patients [8], leading to prolonged hospitalisation, medical complications, higher healthcare cost and increased mortality [6,7]. The high prevalence of malnutrition underscores the need for nurses to improve nutritional care and overcome barriers to providing adequate nutritional care. Barriers like low priority, inflexible food service and limited multidisciplinary support affect how nurses provide nutritional care [9,10].
Nutritional care has always been an essential part of nursing [11]. Evidence-based nutritional treatment and care guidelines are available [12,13]. According to the guidelines, nutritional care includes: screening for nutritional risk, providing an individual nutritional plan, managing the nutritional therapy, monitoring the dietary intake and evaluating and adjusting the nutritional plan [12]. However, nutritional care goes beyond ensuring the patients' dietary needs and becomes complex when nurses adjust dietary recommendations to fit patients' individual preferences and needs [14]. So far, nutritional research has mainly focused on establishing evidence for the nutritional treatment strategies, while less attention has been on the complexity of nursing in providing nutritional care [15].
Identifying needs and problems underlying malnutrition requires competencies within both nursing and nutrition [16][17][18]. While patients value and call for dialogue with nurses as a part of their care [18][19][20], nurses may tend to independently steer clinical decisions concerning nutritional care without including the patients' preferences [21]. Limited time, resources and lack of knowledge and awareness amongst the nurses may stand in the way of integrating individualised nutritional care into daily practice [16,18,21]. When nurses fail to initiate a dialogue, they overlook their patients' nutritional problems [22], resulting in patients feeling unnoticed with unimportant dietary problems [23]. These issues highlight the need for nurse-patient dialogue [18][19][20] and emphasise personcentred care as a foundation for nutritional care. The core elements in person-centred care are patient participation and involvement, the relationship between the patient and the nurses and the context of care [24]. McCormack suggests that nurses move beyond a focus on technical competence and engage in person-centred nursing, which offers a way of reinstating the value of the fundamentals of nursing care [25,26]. Even though nurses recognise the importance of nutritional care, patients still receive inadequate nutritional care [9,21].
The Fundamental of Care (FoC) framework focuses on the patients' essential needs to ensure their physical and psychosocial wellbeing. A core dimension of any nursing action is to establish a positive and trusting nurse-patient relationship [27,28]. The FoC framework explains how each of the following five elements influences the nursespatient relationship: [27] developing trust with the patient, focusing and giving the patients undivided attention, anticipating their needs, knowing enough about the patient to act appropriately and evaluating the quality of the relationship To explore how nurses provide nutritional care, we propose an interpretation of the nutritional care that applies to each of the five elements from the 'Establishing the relationship' as an analytic framework. By focusing on how nurses communicate and interact to establish a relationship with the patients, we can explore elements of importance within nutritional care.

AIM
This study explores how the nurse-patient relationship shapes nutritional care for patients undergoing acute orthopaedic surgery.

METHOD Design
The study is a qualitative secondary deductive analysis of data from single-and focus-group interviews with patients and nurses collected at an orthopaedic ward. The data originate from two previous studies on patients' and nurses' perspectives on nutritional care [21,23]. We aimed to gain further insight into establishing the nursepatient relationship in a clinical setting by including observational data. The combined data represents different research methods and aspects of nutritional care at different time points. To identify meaning units of relevance for establishing the nurse-patient relationship and how the dialogue shapes nutritional care, we defined the five elements from 'Establishing the relationship' from the FoC framework: focusing, knowing, trusting, anticipating and evaluating to comply with nutritional care [24]. See Kitson [27] qualitative research) criteria were used to ensure a comprehensive reporting of the study [29].

Participants and setting
Data were collected at the Amputation and Wound unit and the Hip Fracture unit at the Department of Orthopaedic Surgery in a University hospital in the urban site of Copenhagen. Patients undergoing amputation are characterised by multimorbidity, polypharmacy, low health literacy and socioeconomic status and are most prevalent amongst men with an average age of 68 years, while women tend to be approximately 10 years older [30]. Patients with a hip fracture are also characterised by high age, multimorbidity and frailty [31]. Both patient groups are at high risk of reduced mobility and increased mortality post-surgery. The nursing staff were trained in pre-and post-surgery care [31,32]. This study includes nursing staff with work experience ranging from very experienced to newly qualified nurses, nursing assistants and nurse students. Thirteen nurses from the amputation unit participated in the four focus-group interviews, and 17 patients who had undergone amputation participated in single interviews. Nursing staff from both units participated in the 115 nurse-patient interactions. For this study, the 'nurse-patient relationship' refers to the relationship between patients and nursing staff.

The organisation of nutritional care
The hospital offered a lá carte menu for all patients with several breakfast, lunch and dinner options. The nurses were responsible for supporting the patients in selecting dishes that fulfilled their individual nutritional needs. If a patient could not participate, for example due to physical or cognitive problems, nurses selected the dishes based on their knowledge of patients' preferences. The hospital kitchen delivered the designated meals to each patient on a tray. The nursing staff provided drinks (water, milk or nutritional supplements) when serving the food trays. All meals were served at small tables in the hallway or by the patient's bedside. According to the department's strategy for nutritional therapy, the patient's dietary intake was monitored for 4 days' post-surgery.

Data collection
The first and last author performed the interviews at the department of orthopaedic surgery.
The four focus-group interviews with 13 nurses were performed to identify nurses' perceptions of barriers to nutritional care and lasted between 72-100 min. The interview guide was designed according to the Theoretical Domains Framework [33], and a purposive sampling strategy included nurses from 4 months to 30 years of work experience. All original interviews were transcribed and anonymised for this study. More details have been published [21,23].
The patient interviews were collected as semistructured single face-to-face interviews to examine patients' perspectives on food preferences, dietary counselling and nutritional care following lower extremity amputation. All patients were diagnosed with diabetes or atherosclerosis. The interview guide explored three topics; patient perspective on daily food, experience with the hospital's nutritional care and expectations of food habits following discharge. The participants had a median age of 72 years (46-78 years) and included six women. The interview lasted a median of 43 minutes. (23-65 minutes).
The observational data contain field notes from 23 hours of observations of 115 patient interactions with 48 nursing staff members. The purpose was to explore the nurse-patient dialogue related to nutritional care. The interactions were observed during three care situations: (1) Nursing staff assisting patients ordering from the a la carte menu; (2) Nursing staff serving a meal to the patient; (3) Nursing staffs´ collecting the patients' food tray. The observations were performed using a partly participating approach [34] and carried out in both units over 2 weeks at lunchtime by two bachelor nurse students in their final year, supervised by the first author. The students positioned themselves as students who followed the nursing staff. Field notes were transcribed daily, followed by a more comprehensive description of the observations.

Analysis
The three data sets were anonymised, imported into Excel spreadsheets and deductively analysed using content analysis inspired by Elo & Kyngäs [35]. Prior to the analysis, a structured analysis matrix was developed based on the five elements of 'Establishing the relationship'. To include the nutritional aspect, we propose a new interpretation of the original FoC description of each element (Table 1). To operationalise the matrix, we transformed the original FoC framework questions related to the five-element from, for example 'How do I give you my undivided focus/attention? [24]' to 'How do nurses provide/use/show..?' and 'How do patients respond/express..?', ( Table 1).
The three datasets were thoroughly read and analysed separately using the matrix. First, we identified sections of the original text in the three data sets relevant to this study. These sections were merged into three new datasets. The text was condensed and coded according to the predefined categories in the matrix ( Table 2). The second and last authors conducted the coding separately and discussed it until a consensus was reached. Codes describing the presence or absence of each element were included (Figure 1). A consensus was reached amongst all authors to form the final version of the matrix to validate the analysis. All authors are experienced researchers within the field of qualitative research.

Ethics
According to the Helsinki Declaration, all participants received oral and written information about the purpose of the original studies. The participants were informed about anonymity, confidentiality and the possibility to withdraw at any time before participating. All participants signed a consent form agreeing on publications within the topic of nutritional care. The original studies were reviewed by the Ethical Committee of The Capital Region of Denmark (H-3-2014-FSP67). According to Danish law, studies without invasive procedures do not require formal evaluation. The Danish Data Protection Agency approved the original studies (AHH-2014-041-03395).

RESULTS
The five elements essential for establishing a nurse-patient relationship were identified in all three datasets ( The codes in the grey row exhibit codes for the presence of each element, and the white exhibits codes for the absence. the original FoC description [24], followed by a new proposed description focussing on nutritional care ( Table 1).
The results of each element are first presented from the nurses' perspectives, followed by the patients' and field observations. When relevant, citations are presented to illuminate the analysis.

Focusing
Focusing is present when the nurses give their patients undivided attention during a care interaction and observe or detect changes in their condition. Focusing is not related to time or resources but to the ability to identify the need for care. [24]. Focus in nutritional care is when nurses provide undivided attention by incorporating the patients' nutritional preferences into the care, for example by initiating a nurse-patient relationship ( Table 1). Nurses expressed a wish to be more attentive to the patients' dietary needs and systematically incorporate patients' preferences, eating habits and data from the nutritional screening into the care. Appropriate care was initiated when nurses paid attention, for example dialogue exploring patients´ food preferences. The nurses described a gap between their wish to be attentive to the patients´ dietary needs and the obligation to prioritise tasks in a busy schedule.
The patient's perception of the nutritional care was determined by the nurses' ability to focus on the patient's nutritional issues, ranging from unnecessary to an integrated and essential part of the care. Some patients highlighted the importance of the nurse-patient dialogue as they perceived this to be essential for handling nutritional problems. The patients believed 'the task of' serving meals was unrelated to their nutritional care. The patients describe how the nursing staff could show attention to their nutritional care by reminding them to eat. When nurses explored the patients eating habits and dietary preferences, it highlighted the importance of nutritional care. Additionally, it increased the motivation for eating amongst the patients. The nurses' focus on nutrition made the patients feel less alone in dealing with their nutritional problems. When nurses showed attention to the patients' dietary needs, the patients responded positively by being motivated to eat.

I have an inner motivation, but of course, I feel motivated (to eat, eds.) when they offer me something extra to eat. (Patient 17)
Serving food was observed to be organised as a service task. The trays were transferred to two transportations waggons and were distributed to the patients according to the room number. For the most part, only two to three of the nursing staff participated. The nursing staff prioritised quickly distributing and collecting the patients' meal trays without interacting about nutritional issues.

The nurse places a tray on the patient's bed table. The patient has difficulty getting the lid off the soup. Receive no assistance from the nurse. (field note, 2. observer)
Sometimes the nursing staff offered nutritional alternatives during meal serving, but it was also observed that plates could be placed out of reaching distance without this being noticed by the nurses. When the nursing staff used the meal serving situation to explore the patients' nutritional needs, the focus was on the patients' food preferences, ability to eat or appetite level. When a more F I G U R E 1 Distribution of the codes from interviews and fieldnotes according to the presence or absence of each elements/The five elements from the dimension "Establishing the relationship" within the Fundamentals of Care Framework extended nurse-patient interaction was observed, the nurses engaged with the patients, for example about the diet content.

Knowing
Knowing is when nurses use knowledge about the patients' condition, background or preferences while balancing the need for information with the patient's sense of control, privacy and dignity [24]. Knowledge within nutritional care is when nurses gain knowledge about patients' nutritional state, including using available information to evaluate patients' nutritional issues, for example nutritional preference and integrating relevant information to improve the patients' nutritional status ( Table 1).
The nurses did not routinely explore or document the patient's food preferences. Instead, they used available and easily accessible information from either the nursing or medical record to plan the patients' nutritional care. Consequently, the nursing staff made decisions about nutritional care without involving the patients.

We take action based on what we see and what they need, the patients. We try to suggest and offer other types of food. (Focus group 3)
The patients noted if the nursing staff has had limited insight into their nutritional status and condition. Some patients did not expect the nursing staff to know their eating habits or food preferences as they did not perceive nutrition as a part of their care or treatment. When patients were unable to care for themselves, they highly valued when nurses guided them and discussed possibilities of nutritional supplements.
The patients did not always interpret the nursing staff' actions as linked to their nutritional issues. In contrast, the observations showed that the experienced nurses offered nutritional alternatives and explored the patient's preferences during meal serving more often than the newly qualified nurses or nurse students. When the nursing staff used their knowledge about patients' preferences, it was often related to eating position and the dining environment.

Anticipation
Anticipating is when nurses ask questions or initiate talks about how the patients can be guided or helped to recover or when nurses take actions that promote the patients' physical, mental or emotional state [24]. Anticipation in nutritional care involves exploring the patients' dietary problems or initiating actions to promote and enhance their eating ability ( Table 1).
The nurses described how they could promote the patients' appetite and desire to eat by creating a positive eating environment and serving the food delicately or serving small extra meals. To some nurses, these actions were essential for the patients' care and recovery. Nurses described how nutritional care was often based on the nurses' anticipation of what might be best for the patient rather than identifying the patient's needs in collaboration with the patient.

We probably talk more about the patients between us nurses because I might have been taking care of Joan's patient for the past five days, and I may have noticed something …. So it's something you talk about with your colleagues. I think you could solve a lot of nutritional problems in that way. (Focus group 3)
An ethical dilemma emerged amongst some nurses when patients had a deficiency in their dietary intake, and the nutritional guidelines recommend using a feeding tube in such cases. The dilemma originated from nurses' preferences, experiences and perceptions of whether a feeding tube would violate a patient's autonomy. Thus, the nurses reflected on offering the patient a feeding tube. The nurses, however, seldom involved the patients in their considerations and decisions to include a feeding tube or not.

So, every time we have a patient, and we can see his nutritional needs are not met. Well, then we decide if he should get a feeding tube. (Focus group 2)
When asked directly, the patients expressed that they would accept a feeding tube for recovery and survival. Overall, the patients expressed a need for nurses' support to improve their recovery process but rejected being told what to eat. Instead, they suggested that nurses provide different diet options. Especially the patients with low appetite asked nurses to engage in a dialogue to find the best ways to help them.

I think it is important to talk about what you want to eat and have some choices. I don't feel pressured to eat. They ask me what I would like, and I think that is fine. (Patient 9)
The observations showed positive interactions between nurses and patients when the nurse tempted the patient with new dishes or persuaded the patient to order dessert. The positive nurse-patient relationship was more often observed when nurses assisted patients in ordering dishes than when the nursing staff exclusively ordered the meals.

Evaluating
Evaluating is when both patients and nurses review the patients' progress using feedback and negotiating the goals with others who need to be involved in the patient's rehabilitation [24]. Evaluating nutritional care is when nurses collaborate with the patients to evaluate the patients' nutritional needs by evaluating and adjusting goals within the nutritional plan (Table 1).
Nurses recognised the importance of monitoring the patients' dietary intake to evaluate their nutritional care. In clinical practice, serving meals was viewed as a simple service task that could be performed without knowing the patient. However, this approach was described as problematic because it made evaluating the patient's dietary intake over time difficult.
Well, it's because we help each other deliver and fetch the trays with meals to the patients, and some students don't know that the note (describing the meal's nutritional content) should be saved, or we forget to save it ourselves when we serve meals. And then you don't notice it…. (Focus group 4) The organisation of the nutritional care in clinical practice maintained the evaluation of the nutritional care as a practical task. The practical approach did not support nutritional care as individual care, for example the night-shift nurses were responsible for calculating and documenting the patients' daily dietary intake. The nurses described this as an impossible task and a waste of time.
When patients evaluated the nutritional care, many focused on the food delivery service. Although the patients appreciated the a la carte menu and were delighted with the variety of dishes, the physical environment did not stimulate their desire to eat. Some even described how they felt that nobody cared about whether they were eating or not:

I do not know if anyone noticed (if he had eaten, eds). I did not say anything. I just told them that I had finished my meal, and when I couldn't eat it all, I just kept quiet. (Patient 1)
The dietary intake was not consequently evaluated together with the patients. The observations showed that while some nurses accepted a low dietary intake, others encouraged the patients to try new food items or serve nutritional supplements by involving the patient.
The nurse lifted the lid off the meal trays and notes significant leftovers. The nurses suggest other types of meals. They discuss possibilities, and patients agree to try a sip feed. (Field note)

Trusting
Trust is a prerequisite for establishing a relationship. Trust is formed when nurses exhibit behaviour that indicates the nurse's commitment to the patient's care. The concept of trust in nursing care involves developing a trusting relationship between the individual patient and nurse [24]. A trusting relationship can be established in nutritional care by respecting the patient's experiences and engaging in dialogue (Table 1) The nurses rarely mentioned the importance of establishing a trusting relationship, while the patients more frequently talked about the lack of relationships. The lack of perceived alignment between their duty to care for the patients and the organisation's demands for documentation made the nurses struggle with a feeling of inadequacy. The patients trusted the nurses to know what was best for them. Some patients described themselves as experts in managing their disease and expected to be involved in their care. When the nurses fail to listen to patients´ nutritional concerns or needs, the patients experience a lack of trust.
The observations showed how nurses involved in serving the meals tried to create a pleasant eating environment for the patients but rarely used the short encounters during meal service to establish a patient relationship. The lack of attempt to establish a trusting relationship was observed when the nurses helped patients order their meals without asking them how they were doing.

DISCUSSION
This study explored establishing of the nurse-patient relationship in nutritional care by using the FoC framework as an analytic framework. The findings show that the nurses´ capability to engage in dialogue was essential to establishing a nurse-patient relationship and a prerequisite for providing good nutritional care in the orthopaedic ward. A trusting relationship was established when the nurses were attentive and focused on the patients' individual needs by engaging in a nurse-patient dialogue.
The organisation of the nutritional care as a service task did not support the nurse-patient dialogue related to nutritional care. The nurses often failed to explore and include the patients' preferences and knowledge when making clinical decisions related to nutritional care, which decreased the patients' trust in the nurses.
We found the nursing staff focusing on serving meals and providing nutritional supplements without familiarising themselves with the orthopaedic patients' individual nutritional needs and preferences. Kitson et al. [24] describe that caring is more complex than just doing 'things to people', and Hestevik et al. [36] write that nutritional care goes beyond ensuring sufficient dietary intake [2]. When the food delivery routines shape the nurses' actions to be depersonalised and mechanistic, it may create a disharmonious interrelationship between nurses and the patients. The importance for patients to have a dialogue with the nurses must not be underestimated [37]. The patients in this study were not systematically involved in the decisions making regarding their nutritional care as the nursing staff perceived this as time-consuming, which contrasts with the patients' call for nurses to respond to the patients' needs [38]. Communication that acknowledges the patient's role in care planning can make the difference in avoiding inadequate or missing care [39]. The patients in this study expressed feelings of safety when the nursing staff explored their nutritional needs. However, the patients expressed limited expectations towards the nurses as they believed eating was a personal matter and a part of their self-care. Similarly, Kitson et al. [24] describe a tension between the 'private complexity' performed by a person as a self-care task or activity and the 'public simplicity' performed by an institution, for example as nursing care in a hospital. When patients in this study asked for help to fulfil their nutritional needs and nurses failed to respond, some patients concluded that nutritional care was less important. This finding is supported by Avallin et al. [39] 2020 who describe how feelings of being unimportant will restrain patients from expressing needs, resulting in missed care.
To provide evidence-based and high-quality nutritional care, nurses must align their clinical practice with the recommendation of nutritional guidelines [13,17]. The nurses in this study described feelings of inadequacy when prioritising spending time with the patient rather than complying with the documentation demands and the obligation to perform nutritional screening. One of the key recommendations from the guidelines is to provide an individualised nutritional plan to patients at risk of malnutrition [12]. The nurse's role is generally superficially described in these guidelines, which is problematic as nurses express a need for more knowledge to provide high-quality nutritional care [9,21,40]. The results from this study highlight the relevance of including the FoC framework to provide a more comprehensive description of nursing care and actions within nutritional care. The FoC framework can be used to reflect, understand and operationalise what the guidelines describe as individualised nutritional care.
This study highlights the importance for nurses to anticipate the patient's nutritional challenges. Through patient dialogue, the nurses can secure sufficient and relevant knowledge to assess the patient's ability to eat and plan and perform high-quality nutritional care. The FoC framework highlights the interaction between context and element of care and the dimensions of how care should be provided in combination with a compassionated approach to the patients in need of care [27]. As seen in this study, the patients' request for more dialogue is a clear statement to the nurses. The challenge for nurses is to combine evidence-based knowledge with the nurse-patient relationship to provide good nutritional care that makes sense for both nurses and patients. When the nutritional care is organised and provided as task-oriented, unrelated to the patient's individual needs and preferences, it does not promote high-quality care. Focus on establishing the patients' trust in the nurses and making the nutritional guidelines relevant for nurses is necessary to improve clinical nutritional practice.

Strength and limitation
The methodological strengths of this study are the use of three different data sources to perform a secondary analysis and the use of a well-described framework as an analytic tool to identify the core dimension of the nursepatient relationship. The use of the FoC framework may, however, at the same time be a limitation, as other elements of relevance could be overlooked. Using original data not collected with a focus on the elements of the FoC framework may result in the uneven distribution of codes in the elements. Further, the study's data represent one highly specialised setting, and the results may have a limited application. Finally, it added to the study's credibility that all authors worked closely with the analysis.

CONCLUSION
The nurse-patient dialogue is a prerequisite for establishing a trustworthy relationship, and without such a relationship, nutritional care is at risk of being performed as a service task unrelated to the patients' needs. The patients' need for dialogue must not be compromised due to efficiency demands. More research is needed on how nurses establish the patient relationship in other clinical settings and how this shapes the quality of nutritional care.

AUTHOR CONTRIBUTIONS
All authors contributed to the study design. PSJ and HVP contributed to the data collection. PSJ, VN and HVP contributed to the analysis and preparation of the manuscript. PSJ drafted the manuscript and all authors contributed to the critical revision of the manuscript and approved the final manuscript.

ETHICAL APPROVAL
This study is a secondary analysis and includes data collected in previously approved studies. The Ethical Committee of The Capital Region of Denmark (H-3-2014_ FSP67) reviewed the original studies regarding the patient and nurse interviews and considered not to require formal evaluation as the study design is not within the committee's scope. The Danish Data Protection Agency approved the original studies (2014-041-03395), and no further approval was needed for this secondary analysis. The observational data collection was approved by Danish Data Protection Agency (J.nr.: P-2020-540) as a part of a more extensive study on patients' experiences with nutritional care. All data included in this study were initially collected according to the Helsinki Declaration. All participants received oral and written information about the purpose of the original studies. The participants were informed about voluntary participation, anonymity, confidentiality, and the possibility to withdraw at any time. All participants signed a consent form before participating.